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Panuveitis as a presenting feature of giant cell arteritis
  1. C V RAJESH,
  2. M COLE
  1. Royal Devon and Exeter Hospital, Exeter EX1 2ED
  1. Dr Rajesh

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Editor,—It is unusual for bilateral panuveitis to be a presenting feature of giant cell arteritis. We present a patient diagnosed as having giant cell arteritis who had developed panuveitis some months previously for which the arteritis was probably responsible.

CASE REPORT

A 79 year old woman presented with gradual blurring and photophobia of 6 weeks' duration. There was no significant ocular history. She had had a recent history of weight loss and anorexia for which she underwent endoscopy which revealed a duodenal ulcer. Ophthalmological examination revealed a visual acuity of 6/12 in both eyes. There was no relative afferent pupillary defect. There were bilateral keratic precipitates and cells in anterior chamber and vitreous. The fundus examination revealed bilateral disc oedema, left disc haemorrhages, and multiple raised creamy subretinal peripapillary lesions (Fig 1). The general physical examination was essentially normal. Investigations revealed a hypochromic microcytic anaemia, an erythrocyte sedimentation rate of 87 mm in the first hour, normal angiotensin converting enzyme level, chest x ray, computed tomograph scan of head, orbits, abdomen, and pelvis, abdominal ultrasonography, and autoantibody profile. With the diagnosis of bilateral panuveitis she was started on systemic and topical steroids. The patient improved symptomatically on treatment with the visual acuity improving to 6/9 in both eyes. Ophthalmological examination revealed quiet anterior segments, slightly pale discs with flat subretinal peripapillary lesions, and there were no cells in the vitreous. Systemic steroids were gradually tapered over next few months. A year later she complained of further blurring, continuing weight loss, myalgia, and arthralgia. On examination she had visual acuities of 6/12 in the right eye and 6/18 in the left eye with quiet anterior segments, no relative afferent pupillary defect, and fundus changes similar to the previous episode with bilateral disc oedema, raised peripapillary creamy subretinal lesions with cells in the vitreous. She was also found to have non-pulsatile, non-tender temporal arteries. A temporal artery biopsy was performed which showed evidence of giant cell arteritis.

Figure 1

Bilateral disc oedema, multiple peripapillary creamy lesions, and left disc haemorrhage.

COMMENT

Partial or complete visual loss is the most common and the most serious ophthalmic complication of giant cell arteritis. Because giant cell arteritis is a potentially blinding disease and its early diagnosis is the key to preventing blindness, it is important to recognise its various ocular manifestations.1 Panuveitis as a presenting feature is uncommon and to the best of our knowledge this is the first report of a subacute panuveitis as a presenting feature of giant cell arteritis. There is one another case reported where the presenting feature was acute anterior and posterior uveitis.2 The fluorescein angiogram showed leakage from the subretinal peripapillary lesions and the optic discs (Fig 2) and there was no wedge shaped alteration suggestive of choroidal ischaemia.3 Although this patient had a history of weight loss and high erythrocyte sedimentation rate at presentation the diagnosis of giant cell arteritis was not considered because of this unusual presentation. Serum angiotensin converting enzyme levels, chestx ray, computed tomograph scans of abdomen and pelvis were done to exclude sarcoidosis and lymphoma. In conclusion we describe a case in which giant cell arteritis offers a possible explanation for the clinical picture of subacute panuveitis in the absence of an exhaustive search for an underlying cause.

Figure 2

Fluorescein leakage from the subretinal peripapillary lesions and optic disc.

References

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